Medicare Call Compliance: CMS Rules QA Teams Should Monitor

QA teams on Medicare Advantage and Part D sales calls should check, on every call, that the agent read the TPMO disclaimer within the first minute, did not imply they represent Medicare or the government, documented the scope of appointment before discussing plans, described benefits and costs accurately, covered the required pre-enrollment topics, and got clear permission before any transfer. The core rules are in 42 CFR 422 and 423 subpart V, with the TPMO disclaimer at 42 CFR 422.2267(e)(41) and 423.2267(e)(41).

This guide turns those rules into a call QA checklist for agencies, call centers and BPOs that run Medicare and insurance campaigns. It is general information, not legal advice. CMS updates these rules often, and carriers add their own requirements, so confirm your scorecard with your compliance team and your carriers.

What is a TPMO?

A third party marketing organization (TPMO) is defined in 42 CFR 422.2260 as an organization or individual compensated to perform lead generation, marketing, sales or enrollment for a Medicare Advantage or Part D plan. That includes many independent agents, agencies, field marketing organizations and the call centers they hire. If your floor takes or makes Medicare plan calls on behalf of plans or agents, assume TPMO rules apply until your compliance team says otherwise.

The TPMO disclaimer: what QA should check

Under 42 CFR 422.2267(e)(41) and 423.2267(e)(41), TPMOs must give a standardized disclaimer. On the phone, it must be verbally conveyed within the first minute of a sales call. The disclaimer tells the beneficiary, in substance:

• The TPMO does not offer every plan available in their area.
• How many organizations and plans the TPMO currently represents in the area, or that the information given is limited to the plans the TPMO offers.
• That they can contact Medicare.gov, 1-800-MEDICARE or their local State Health Insurance Assistance Program (SHIP) for information on all their options.

Pull the exact current wording from the regulation or your plan partners rather than from a blog, including this one. Then score it like this:

1. Was it read? Missing equals a fail, and it should be a critical item.
2. Was it read in time? Check the timestamp. If the agent reads it at minute four, it was read, but not within the first minute.
3. Was it complete? Agents shorten scripts under pressure. Dropping the Medicare.gov, 1-800-MEDICARE or SHIP reference is a common partial.
4. Were the numbers right? The count of organizations and plans should match what your agency actually represents in that area.

Medicare call compliance checklist for QA

Opening

• Agent name and agency stated. The beneficiary knows who they are talking to.
• No implied government affiliation. The agent does not say or imply they are calling from Medicare, Social Security or the government. Misleading communications are prohibited under 42 CFR 422.2262 and 423.2262.
• Recording notice. The call is recorded, and the beneficiary is told where your state law or carrier requires it.
• TPMO disclaimer within the first minute, as above.
• Permission based contact. CMS prohibits unsolicited contact such as cold calls to beneficiaries (42 CFR 422.2264(b)). Outbound calls should be ones the beneficiary asked for. QA can check whether the agent referenced the request, and your lead source records should back it up.

Before discussing plans

• Scope of appointment (SOA). 42 CFR 422.2264(c)(3) requires the agent to agree with the beneficiary on the scope of the appointment, documented before the meeting. A 48 hour waiting period between the SOA and the appointment applies, with limited exceptions. On a recorded call, check that the agent confirmed the products to be discussed and that a valid SOA exists.
• Stayed inside the scope. The agent did not drift into products the beneficiary did not agree to discuss.

During the plan discussion

• Accurate benefits and costs. Premiums, copays, drug coverage and extra benefits are described correctly, with no "free" or "guaranteed" claims the plan does not support.
• Doctors and drugs checked. The agent asked about current doctors, pharmacies and prescriptions before recommending a plan.
• No pressure. No false urgency such as "you will lose your benefits if you do not switch today."
• Required pre-enrollment topics. CMS requires agents to review specific information before enrollment, such as how the new plan affects current coverage, network rules and costs. Use your carriers' current Pre-Enrollment Checklist and 42 CFR 422.2274 for the exact list.

Transfers and enrollment

• Permission to transfer. On lead generation or fronter calls, the agent asked before transferring to a licensed agent and told the beneficiary who they would speak with.
• Clear consent to enroll. The beneficiary clearly agreed to the specific plan.
• Recap. Plan name, effective date and what happens next were stated.

Recording requirements for TPMOs

CMS rules in 42 CFR 422.2274 and 423.2274 require TPMOs to record marketing, sales and enrollment calls in their entirety, including the audio of virtual calls, and plans must oversee their TPMOs. Two practical points for QA:

• Recording every call means you already have the evidence. The gap is usually that nobody reviews most of it.
• Check your retention policy against CMS and carrier requirements. If your QA tool deletes its copy of the audio after a set period, keep the original recordings in your dialer or archive for as long as required.

Medicare vs ACA vs final expense: what changes

Insurance floors often run several products. The disclaimer and checks are not the same.

Build a separate scorecard for each product line. A single "insurance" scorecard either misses items or marks them not applicable so often that it becomes noise. See our insurance and Medicare industry page for the flags most agencies start with.

How to set up QA for Medicare calls

1. Write the exact disclaimer your agency uses into a criterion and mark it critical.
2. Add timing. The disclaimer criterion should require it within the first minute, not just "at some point."
3. List the other critical items: government implication, misleading benefit claims, transfer without permission.
4. Add product specific skill items such as needs analysis, doctor and drug check, and recap.
5. Calibrate with your compliance lead on a set of real calls before you rely on automated scores.
6. Review every critical failure by hand before reporting it to a carrier or using it for discipline.

Our QA scorecard template is a good base to adapt.

What the numbers say about Medicare marketing

• Marketing complaints rose sharply. A U.S. Senate Committee on Finance majority staff report quotes CMS, in its May 2022 Medicare Advantage rule, as receiving 15,497 marketing related complaints in 2020 and 39,617 in 2021, excluding December. The Commonwealth Fund put the 2021 total at more than 41,000 complaints about Medicare private plan marketing, more than double the number in 2020.
• Agents are a main channel. Nearly one third of Medicare beneficiaries age 65 and older say they turn to an insurance broker or agent, according to the Commonwealth Fund in 2023.
• Telemarketing rules add exposure. Outside CMS rules, the Telephone Consumer Protection Act at 47 U.S.C. 227 lets a person recover the greater of their actual loss or $500 per violation, which a court can raise to up to three times for a willful or knowing violation.

Complaint counts are not the same as proven violations, and many beneficiaries never complain at all. The practical point for a floor is that marketing calls get scrutiny, so you want to know what your agents said before a carrier or regulator asks.

Why every Medicare call needs checking

Annual Enrollment Period volume makes sampling especially weak. A single agent can make many calls a day, and a skipped disclaimer or a careless "free" claim repeats across all of them. Carriers and CMS can review recordings after the fact. Knowing your own miss rate first is cheaper than learning it from an audit. See manual QA compared with full coverage.

How Sillana helps

Sillana connects to your dialer and scores every recorded call against the scorecard you write. Add your exact disclaimer and Sillana checks each call for it, marking pass, partial or fail with the quote it found, so a reviewer can see in seconds whether it was complete. Critical items such as a missing disclaimer are flagged for review. Sillana checks what was said on the call. It does not verify your SOA records, lead consent or licensing, and it does not replace your compliance team. Recordings and transcripts in Sillana are removed after 90 days, so keep your source recordings wherever your retention policy requires. Plans are on the pricing page.

Key takeaways

• The TPMO disclaimer (42 CFR 422.2267(e)(41) and 423.2267(e)(41)) must be read within the first minute of a sales call. Score both presence and timing.
• Scope of appointment, no government implication, accurate benefits and pre-enrollment topics belong on every Medicare scorecard.
• Medicare, ACA and final expense need separate scorecards.
• Review critical failures by hand before acting on them.
• This is general information, not legal advice. Check current rule text and carrier guidance before you finalize your scorecard.

Questions people ask